DIVISION OF HEALTHCARE FINANCING CMS 1500 ICD-10 October 1, 2017
General Information Overview Thank you for your willingness to serve clients of the Medicaid Program and other medical assistance programs administered by the Division of Healthcare Financing. This manual supersedes all prior versions. Rule References Providers must be familiar with all current rules and regulations governing the Medicaid Program. Provider manuals are to assist providers with billing Medicaid; they do not contain all Medicaid rules and regulations. Rule citations in the text are only a reference tool. They are not a summary of the entire rule. In the event that the manual conflicts with a rule, the rule prevails. Wyoming State Rules may be located at, http://soswy.state.wy.us/rules/default.aspx. CMS 1500 ii Revision 10/1/17
General Information Importance of Fee Schedules and Provider s Responsibility Procedure codes listed in the following Sections are subject to change at any time without prior notice. The most accurate way to verify coverage for a specific service is to review the Medicaid fee schedules on the website (2.1, Quick Reference). Fee schedules list Medicaid covered codes, provide clarification of indicators, such as whether a code requires prior authorization and the number of days in which followup procedures are included. Not all codes are covered by Medicaid or are allowed for all taxonomy codes (provider types). It is the provider s responsibility to verify this information. Use the current fee schedule in conjunction with the more detailed coding descriptions listed in the current CPT-4 and HCPCS Level II coding books. Remember to use the fee schedule and coding books that pertain to the appropriate dates of service. Wyoming Medicaid is required to comply with the coding restrictions under the National Correct Coding Initiative (NCCI) and providers should be familiar with the NCCI billing guidelines. NCCI information may be reviewed at http://www.cms.gov/medicare/coding/nationalcorrectcodinited/index.html. Getting Questions Answered The provider manuals are designed to answer most questions; however, questions may arise that require a call to a specific department such as Provider Relations or Medical Policy (2.1, Quick Reference). Medicaid manuals, bulletins, fee schedules, forms, and other resources are available on the Medicaid website or by contacting Provider Relations. CMS 1500 iii Revision 10/1/17
General Information AUTHORITY The Wyoming Department of Health is the single state agency appointed as required in the Code of Federal Regulations (CFR) to comply with the Social Security Act to administer the Medicaid Program in Wyoming. The Division of Healthcare Financing (DHCF) directly administers the Medicaid Program in accordance with the Social Security Act, the Wyoming Medical Assistance and Services Act, (W.S. 42-4-101 et seq.), and the Wyoming Administrative Procedure Act (W.S. 16-3-101 et seq.). Medicaid is the name chosen by the Wyoming Department of Health for its Medicaid Program. This manual is intended to be a guide for providers when filing medical claims with Medicaid. The manual is to be read and interpreted in conjunction with Federal regulations, State statutes, administrative procedures, and Federally approved State Plan and approved amendments. This manual does not take precedence over Federal regulation, State statutes or administrative procedures. THE FOLLOWING PAGES ARE EXCERPTS ON TELEHEALTH TAKEN FROM THIS MANUAL CMS 1500 iv Revision 10/1/17
Resubmit the entire claim or denied line only after all corrections have been made. Contact Provider Relations (2.1, Quick Reference): o With any questions regarding billing or denials. o When payment has not been received within 30-days of submission, verify the status of the claim. o When there are multiple denials on a claim, request a review of the denials prior to resubmission. NOTE: Once a provider has agreed to accept a patient as a Medicaid client, any loss of Medicaid reimbursement due to provider failure to meet timely filing deadlines is the responsibility of the provider. 6.24 Telehealth Telehealth is the use of an electronic media to link beneficiaries with health professionals in different locations. The examination of the client is performed via a real time interactive audio and video telecommunications system. This means that the client must be able to see and interact with the off-site practitioner at the time services are provided via telehealth technology. It is the intent that telehealth services will provide better access to care by delivering services as they are needed when the client is residing in an area that does not have specialty services available. It is expected that this modality will be used when travel is prohibitive or resources won t allow the clinician to travel to the client s location. Each site will be able to bill for their own services as long as they are an enrolled Medicaid provider (this includes out-of-state Medicaid providers). 6.24.1 Covered Services Originating Sites (Spoke Site) The Originating site or Spoke site is the location of an eligible Medicaid client at the time the service is being furnished via telecommunications system occurs. Authorized originating sites are: Hospitals Office of a physician or other practitioner (this includes medical clinics) Office of a psychologist or neuropsychologist Community mental health or substance abuse treatment center (CMHC/SATC) Office of an advanced practice nurse (APN) with specialty of psych/mental health Office of a Licensed Mental Health Professional (LCSW, LPC, LMFT, LAT) Ch. 6 Index 109 Revision 10/1/17
Federally Qualified Health Center (FQHC) Rural Health Clinic (RHC) Skilled nursing facility (SNF) Indian Health Services Clinic (IHS) Hospital-based or Critical Access Hospital-based renal dialysis centers (including satellites). Independent Renal Dialysis Facilities are not eligible originating sites. Developmental Center Family Planning Clinics Public Health Offices Client s Home (Telehealth consent form must be completed and kept in the client s medical records) Distant Site Providers (Hub Site) The location of the physician or practitioner providing the professional services via a telecommunications system is called the distant site or Hub site. A medical professional is not required to be present with the client at the originating site unless medically indicated. However, in order to be reimbursed, services provided must be appropriate and medically necessary. Physicians/practitioners eligible to bill for professional services are: Physician Advanced Practice Nurse with specialty of Psychiatry/Mental Health Physician s Assistant Psychologist or Neuropsychologist Licensed Mental Health Professional (LCSW, LPC, LMFT, LAT) Speech Therapist Provisionally licensed mental health professionals cannot bill Medicaid directly. Services must be provided through an appropriate supervising provider. Services provided by non-physician practitioners must be within their scope(s) of practice and according to Medicaid policy. For Medicaid payment to occur, interactive audio and video telecommunications must be permitting real-time communication between the distant site physician or practitioner and the patient with sufficient quality to assure the accuracy of the assessment, diagnosis, and visible evaluation of symptoms and potential medication side effects. All interactive video telecommunication must comply with HIPAA patient privacy regulations at the site where the patient is located, the site where the consultant is located, and in the transmission process. If distortions in the transmission make adequate diagnosis and assessment improbable and a presenter at the site where the patient is located is unavailable to assist, the visit must be halted and rescheduled. It is not appropriate to bill for portions of the evaluation Ch. 6 Index 110 Revision 10/1/17
unless the exam was actually performed by the billing provider. The billing provider must comply with all licensing and regulatory laws applicable to the provider s practice or business in Wyoming and must not currently be excluded from participating in Medicaid by state or federal sanctions. Hub Sites Billing Code(s) (site with provider) CPT-4 and HCPCS Level II Codes Modifier Description 99241-99255 GT Consultations 99201-99215 GT Office or other outpatient visits 90832-90838 GT Psychotherapy 90791-90792 GT Psychiatric diagnostic interview examination 96116 GT Neurobehavioral status exam 90951,90952,90954,90955,90957,90958,90960 and 90961 GT End stage renal disease related services Individual medical nutrition G0270 GT therapy H0031, H2019, T1017, G9012 GT Mental Health and Substance Abuse Treatment Services 92586, 92602, 92604, 92626 GT Remote Cochlear Implant Modifier GT Description Telehealth Service Spoke Site Billing Code (site with patient) HCPCS Level II Code Q3014 Description Telehealth originating site facility fee For accurate listing of codes, refer to the fee schedule on the Medicaid website (2.1, Quick Reference). 6.24.2 Non-Covered Services Telehealth does not include a telephone conversation, electronic mail message (email), or facsimile transmission (fax) between a healthcare practitioner and a client, or a consultation between two health care practitioners asynchronous store and forward technology. Group psychotherapy is not a covered service. Ch. 6 Index 111 Revision 10/1/17
6.24.3 Billing Requirements In order to obtain Medicaid reimbursement for services delivered through telehealth technology, the following standards must be observed: Telehealth Consent form must be completed if the originating site is the client s home. The services must be medically necessary and follow generally accepted standards of care. The service must be a service covered by Medicaid. Claims must be made according to Medicaid billing instructions. The same procedure codes and rates apply as for services delivered in person. Quality assurance/improvement activities relative to telehealth delivered services need to be identified, documented and monitored. Providers need to develop and document evaluation processes and patient outcomes related to the telehealth program, visits, provider access, and patient satisfaction. All service providers are required to develop and maintain written documentation in the form of progress notes the same as is originated during an in-person visit or consultation with the exception that the mode of communication (i.e. teleconference) should be noted. Medicaid will not reimburse for the use or upgrade of technology, for transmission charges, for charges of an attendant who instructs a patient on the use of the equipment or supervises/monitors a patient during the telehealth encounter, or for consultations between professionals. o The modifier to indicate a telehealth service is GT which must be used in conjunction with the appropriate procedure code to identify the professional telehealth services provided by the distant site provider (e.g., procedure code 90832 billed with modifier GT). GT modifier MUST be billed by the distant site. Using the GT modifier does not change the reimbursement fee. o When billing for the originating site facility fee, use procedure code Q3014. A separate or distinct progress note isn t required to bill Q3014. Validation of service delivery would be confirmed by the accompanying practitioner s claim with the GT modifier indicating the practitioner s service was delivered via telehealth. Medicaid will reimburse the originating site provider the lesser of charge or the current Medicaid fee. o Additional services provided at the originating site on the same date as the telehealth service may be billed and reimbursed separately according to published policies and the national correct coding initiative guidelines. o For ESRD-related services, at least one (1) face-to-face, hands on visit (not telehealth) must be furnished each month to examine the vascular access site by a qualified provider. Ch. 6 Index 112 Revision 10/1/17
NOTE: If the patient and/or legal guardian indicate at any point that he/she wants to stop using the technology, the service should cease immediately and an alternative appointment set up. 6.24.4 Telehealth Consent Form NOTE: Click image above to be taken to a printable version of this form. 6.24.5 Telehealth Consent Form Instructions Beginning October 1, 2017 Wyoming Medicaid will allow the client s home to be a valid Origination site. Written client consent is required. Completion: The appropriate person at either the client s site or the health care practitioner site completes the form and obtains the client's signature prior to the services. Distribution: The original form is completed by the provider of the telehealth service and is retained in the client s medical record. A copy is also given to the client or parent/guardian. Ch. 6 Index 113 Revision 10/1/17
Field Client Name Type of Service Provider Name Facility Name and Address Alternative Services Signature and date Signature of Person Obtaining Consent Facility Name Facility Address Action Enter the client s name Define the service to be provided as a telehealth service on the second line Enter the name of the health care practitioner who will be seeing the client from the distant site Enter the facility name and address of the distant site where the health care practitioner is located Describe in writing any other options that are available to the client The client, parent or legal representative must sign and date the form Person obtaining consent must sign and date the form Enter the Facility for the person obtaining consent Enter the Facility address for the person obtaining consent Ch. 6 Index 114 Revision 10/1/17